title: Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial).
abstract: OBJECTIVE
  To develop and evaluate a best practice model of general hospital acute medical care for older people with cognitive impairment.
  
  
  METHODS
  Randomised controlled trial, adapted to take account of constraints imposed by a busy acute medical admission system.
  
  
  METHODS
  Large acute general hospital in the United Kingdom.
  
  
  METHODS
  600 patients aged over 65 admitted for acute medical care, identified as "confused" on admission.
  
  
  METHODS
  Participants were randomised to a specialist medical and mental health unit, designed to deliver best practice care for people with delirium or dementia, or to standard care (acute geriatric or general medical wards). Features of the specialist unit included joint staffing by medical and mental health professionals; enhanced staff training in delirium, dementia, and person centred dementia care; provision of organised purposeful activity; environmental modification to meet the needs of those with cognitive impairment; delirium prevention; and a proactive and inclusive approach to family carers.
  
  
  METHODS
  
  
  
  METHODS
  number of days spent at home over the 90 days after randomisation.
  
  
  RESULTS
  structured non-participant observations to ascertain patients' experiences; satisfaction of family carers with hospital care. When possible, outcome assessment was blind to allocation.
  
  
  RESULTS
  There was no significant difference in days spent at home between the specialist unit and standard care groups (median 51 v 45 days, 95% confidence interval for difference -12 to 24; P=0.3). Median index hospital stay was 11 versus 11 days, mortality 22% versus 25% (-9% to 4%), readmission 32% versus 35% (-10% to 5%), and new admission to care home 20% versus 28% (-16% to 0) for the specialist unit and standard care groups, respectively. Patients returning home spent a median of 70.5 versus 71.0 days at home (-6.0 to 6.5). Patients on the specialist unit spent significantly more time with positive mood or engagement (79% v 68%, 2% to 20%; P=0.03) and experienced more staff interactions that met emotional and psychological needs (median 4 v 1 per observation; P<0.001). More family carers were satisfied with care (overall 91% v 83%, 2% to 15%; P=0.004), and severe dissatisfaction was reduced (5% v 10%, -10% to 0%; P=0.05).
  
  
  CONCLUSIONS
  Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use. Patients' experience and carers' satisfaction might be more appropriate measures of success for frail older people approaching the end of life.
  
  
  BACKGROUND
  Clinical Trials NCT01136148.
authors.affiliation: Division of Rehabilitation and Ageing, University of Nottingham, Nottingham NG7 2UH, UK.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Goldberg
authors.forename: Lucy E
authors.initials: LE
authors.lastname: Bradshaw
authors.forename: Fiona C
authors.initials: FC
authors.lastname: Kearney
authors.forename: Catherine
authors.initials: C
authors.lastname: Russell
authors.forename: Kathy H
authors.initials: KH
authors.lastname: Whittamore
authors.forename: Pippa E R
authors.initials: PE
authors.lastname: Foster
authors.forename: Jil
authors.initials: J
authors.lastname: Mamza
authors.forename: John R F
authors.initials: JR
authors.lastname: Gladman
authors.forename: Rob G
authors.initials: RG
authors.lastname: Jones
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Lewis
authors.forename: Davina
authors.initials: D
authors.lastname: Porock
authors.forename: Rowan H
authors.initials: RH
authors.lastname: Harwood
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000628:therapy*; D003693:Delirium / Q000628:therapy; D003704:Dementia / Q000628:therapy; D005260:Female; D006760:Hospitalization; D006769:Hospitals, General; D006801:Humans; D007902:Length of Stay; D008297:Male; D009483:Neuropsychological Tests; D017063:Outcome Assessment, Health Care; D010359:Patient Readmission; D011567:Psychiatric Department, Hospital; D011787:Quality of Health Care; D011788:Quality of Life; D006113:United Kingdom